According to the inspection report, this transition created dangerous gaps in medical coverage that lasted over a month.
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These individuals may wander, fall, become agitated, or engage in behaviors that could harm themselves or others.
June showed similar patterns with AM temperatures recorded just 3 out of 30 days and PM temperatures documented only 2 out of 30 days.
This created dangerous delays during critical moments when every second matters for patient survival.
Federal regulations require facilities to immediately notify physicians and family members when residents experience significant changes in condition.
The incident occurred in February 2025 when the CNA disregarded established protocols.
The violations occurred despite facility policies requiring all medications to be stored in locked compartments inaccessible to residents and visitors.
The situation became so concerning that it was **reported to the sheriff's office** for investigation.
Between monitoring checks, the resident successfully cut her right wrist with a microblade razor she had ordered online.
When investigators interviewed Resident 1, they found her call light cord wrapped around the bed frame and completely out of reach.
The resident was subsequently hospitalized and diagnosed with cerebral infarction, hemiparesis affecting the right dominant side, and slurred speech.
The resident, who has been receiving dialysis for many years due to end-stage renal disease, reported concerning gaps in post-treatment monitoring.